Which items are appropriate for the nurse to include when assessing a client for falls?
1. Reviewing for a history of falls before admission
2. Talking with family about concerns
3. Assessing the overall physical condition
4. Assessing medication lists
5. Assessing mental status
1,3,4,5
Rationale 1: It is appropriate for the nurse to review the client's medical record for any history of falls as this serves as a baseline for how to proceed when planning care for this client.
Rationale 2: Talking to the family is important, but unless the family is staying with the client it is not warranted at this time.
Rationale 3: Assessing the client's overall condition is necessary as the client may need ambulatory devices.
Rationale 4: Assessing medications is important as many medications can alter balance and therefore lead to increased falls.
Rationale 5: Assessing mental status is important and is critical to determining fall risks.
Global Rationale: It is important for the nurse to review the client's medical record for any history of falls along with assessing the client's overall condition, medications, and mental status. All are important to determine the client's risk for falls. Talking to the family is important, but unless the family is staying with the client it is not warranted at this time.
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